Employee Forms and Benefits Page

Monroeville Employee Forms and Benefits
Click on the links below to download forms.

General
Employment Application
Full Time Employee Check List	Employee Handbook and Safety Manual
Part Time Employee Check List	Summer/Part-Time Employee Handbook
Change of Address	Personal Budget Spreadsheet (Excel)
Human Resource Info Form	MOM Library Makers Lab Fee Waiver

Credit Union - Now USX www.usxfcu.org
Representative Contact: Renee Jessee 1 888 219 3159 Or by Email at RLJessee@usxFCU.org
USX Enrollment Form	USX Payroll Deduction
Vehicle-Personal-Loan-Application	2025 Benefits Flyer

Employee Payroll and Benefits
Payroll
W-4 (2025)	Direct Deposit of Paycheck
W-4P (2025)	Local Services Tax Refund Application
I-9, Employment Eligibility Verification	Local Services Tax Exemption Certificate
Earned Income Tax Residency Certification

Miscellaneous Employee Forms
Form 1000 Hire Authorization and New Position Request (yellow sheet)
Form 2000 Employee Status Change Request/Notification (blue sheet)
Form 3000 Employee Performance Evaluation
Form 4000 Accident Report (orange sheet)
Form 7000 Request for Outside Employment
Employee Flex Time Policy and Request Form (11/09/2023)
Leave Without Pay Form
Employee Vacation Carry-Over Request Form
Employee Expense Form (4/4/2025)
Fill-in Employee Expense Form (Excel) (4/4/2025)
MOM Per Diem Expense Policy 2025-04-02 AJG Signed (4/4/2025)
Physician Certification for Family or Medical Leave
Continuing Education Approval and Refund Application
Professional Meeting/Seminar/Training Attendance Request
Employee Observation Report
Public Works Union Dues Form

Police Miscellaneous Forms
Police FOP Deduction Form
Police Union Dues Deduction Form
Police Flower Fund Deduction Form

Deferred Compensation
457 Plan Salary Deferral Form
Mission Square 457 Plan - Client Services 1-800-669-7400
Mission Square Retirement Plan Representative - Erik Gabrich - egabrich@missionsq.org - Work #202-759-7018 - Work Cell #202-430-3688
Mission Square 457 Enrollment
Website - https://www.missionsq.org/

Capital Group / American Funds (800) 421-4225
American Funds 457 Plan Enroll
American Funds 457 Funds List

Nationwide 457 Plan - 1-877-677-3678 www.nrsforu.com
	Participation Agreement 457(b)

Disability Insurance Benefits
Monroeville Short Term Disability Form

Life Insurance
Aflac - Dan Marcin 412-826-1840	www.aflac.com
Conseco - 1-800-283-8075	www.conseco.com
Active Police - Life Insurance Enrollment-Change
Municipal - Life Insurance Enrollment-Change
Standard Insurance Group Life Policy

Pension
Police Pension - Debbie Rall - 412 562-8216 drall@janney.com
Nomination of Beneficiaries/Instructions (Police only)
Non-Police Pension 1-800-622-7968
PMRS Pension Plan Enrollment Form
PMRS Pension Beneficiary Form
PMRS Notification of Demographic Change (fillable)
PMRS website - www.pmrs.state.pa.us
Employee Pension Plan Brochure (Non-Uniform)
Police Pension Deposit Slip

Workers Compensation
Workers' Compensation Employee Notification
Form 4000, Accident Report
Workers' Compensation Provider Panel
Municipality of Monroeville - The Workforce Protocol

Ordinances
2798 Monroeville NonUnion Salary Structure 2025
2801, Benefits, Monroeville Exempt and Non-Exempt Employees

2773, Police Collective Bargaining Agreement 2023

2788, SEIU Clerical Workers & TCO Collective Bargaining Agreement 2024

2800, Public Works/Refuse Collective Bargaining Agreement 2025-2028

2198, Military Leave Policy

Library Personnel Policy Manual 2019

Health Care
Highmark Blue Cross/Blue Shield Member Service Questions 800-241-5704
UPMC Contact Info: UPMC Member Services 1-888-876-2756
UPMC Health Advocate Assistance 1-866-695-8622

Healthcare && Dental Application
Highmark Employee Wellness website
Healthcare Employee Amounts
SEIU Healthcare Employee Amounts
UPMC 2024 Preventive Schedule
Highmark 2024 Preventive Schedule
PPO Blue 1500Q Benefits Grid
Health Care Insurance Rebate Form
Medco Mail Order Pharmacy Handbook
Prescription Reimbursement Form
HighMark HRA Reimbursement Form
Medco By Mail Order Form
Blue Card Global Info
Health Advocate 1-866-695-8622

Dental United Concordia 1-800-332-0366
Concordia Network Dental Plan Policy
Concordia Dental Benefits Summary 2024	Concordia Dental ID Card Update

Health Savings Plans RHS Plan - Mission Square - 1-800-290-7158 https://www.missionsq.org/
Mission Square RHS Enrollment Form
Mission Square RHS Employee Q&A

Vision 1-800-432-4966 www.vbaplans.com/vision/

Vision Care
Group Vision Care Summary	Vision Benefits of America Enrollment



Legal Shield
Representative Contact: Lorraine Backus 330-784-2917 Or by Email at backus50@gmail.com Employee Weblink: Legal Shield Benefits
LegalShield Benefits
EAP Program
Employee Assistance Program
EAP Program Description	EAP Program

TAP 529 Tuition Program
Contact: 800-440-4000
Tap 529 Payroll Deduction Form

Washington National
Website: WashingtonNational.com
POC: Zachary Smith
Phone: 304-588-9656
Email: Zachary.Smith@optavise.com

Aflac
POC: Dan Marcin 412-826-1840	Website: Aflac.com